Pride Health · 3 hours ago
members appeals specialist
United States
Contract
Remote
New Grad, Entry Level
$21/hr - $23/hrPride Health is seeking a Member Appeals Specialist to support a high-volume health plan appeals team. The role focuses on managing member appeals for pre-service pharmacy coverage and requires strong attention to detail and case management skills in a fully remote environment.
Health CareHuman ResourcesInformation Technology
Hiring Manager
Chirag Shah
Responsibilities
Triage incoming member appeals and grievances, categorize appropriately, and assign cases per workflow
Manage appeals end-to-end, from assignment through final decision
Evaluate appeal timeliness and member eligibility
Issue acknowledgment letters using system templates (with case-specific edits)
Review appeal requests to determine need for additional medical records or Appointment of Representative forms
Conduct outbound calls to obtain missing documentation or clarify information
Collaborate with internal teams including Appeals Specialists, Supervisors, Quality Nurses, Medical Directors, and Pharmacy teams
Draft appeal decision notices using approved templates and reference materials to ensure regulatory compliance
Manage an active caseload of ~40 cases while meeting required turnaround times
Use multiple systems including Jiva, PBM tools (Express Scripts), Facets, Outlook, Teams, Zoom, and Avaya
Qualification
Required
Experience handling member appeals (provider claim appeals alone will not be sufficient; combo experience is a plus)
Comfortable managing appeals within a system of record from start to finish
Strong written and verbal communication skills with professional email etiquette
Highly detail-oriented, organized, and reliable
Able to work independently while collaborating effectively in a 100% remote environment
Willingness and enthusiasm to learn reference materials and follow compliance-driven workflows
Benefits
Comprehensive healthcare coverage (medical, dental, and vision plans)
Supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity)
401(k)-retirement savings
Life & disability insurance
An employee assistance program
Legal support
Auto, home insurance
Pet insurance
Employee discounts with preferred vendors
Company
Pride Health
Pride Health is a staffing and recruiting company that provides account management and staffing solutions.
Founded in 2010
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Stephanie Barnes
Scheduling Lead PHC/OPWDD
Recent News
2025-11-06
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